Healthcare Provider Details

I. General information

NPI: 1528609534
Provider Name (Legal Business Name): JAMES HYUNSEOK PAK ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2019
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FODEN RD
SOUTH PORTLAND ME
04106-2327
US

IV. Provider business mailing address

20 EASTVIEW CT APT 2
BIDDEFORD ME
04005-2818
US

V. Phone/Fax

Practice location:
  • Phone: 207-780-8860
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT893
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: